Homeopathic prescribing for chronic and acute periodontal ...

Homeopathy (2013) 102, 242e247 ? 2013 The Faculty of Homeopathy

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ORIGINAL PAPER

Homeopathic prescribing for chronic and acute periodontal conditions in 3 dental practices in the UK

S Farrer1,*, ES Baitson2, L Gedah1, C Norman1, P Darby1 and RT Mathie2

1Faculty of Homeopathy, 29 Park Street West, Luton LU1 3BE, UK 2British Homeopathic Association, 29 Park Street West, Luton LU1 3BE, UK

Introduction: This investigation extends our previous dental data collection pilot study with the following main aims: to gain insight into the periodontal complaints that dentists in the UK treat using individualised homeopathic prescription; to record patientassessed change in severity of treated complaint (acute or chronic); to determine periodontal pocket depth (PPD). Materials and methods: Three dentists recorded data systematically at 249 homeopathic appointments in 51 patients over a period of 18 months. A spreadsheet enabled the data collection of the following records: date of appointment; anonymised patient identity; main periodontal problem treated; whether the condition was acute or chronic; patient-assessed clinical outcome on a 7-point Likert scale, ranging from ?3 to +3, to compare the first and any subsequent appointments; whether any interventional dental surgery (IDS) had been carried out; clinician-assessed PPD measurements. Results: At least one follow-up (FU) appointment was reported for each of 46 patients (22 chronic [6 with IDS, 16 without IDS]; 24 acute [10 with IDS, 14 without IDS]). In chronic cases, strongly positive outcomes (score of +2 or +3) were reported by 2 (33.3%) of 6 IDS patients and by 1 (6.3%) of 16 non-IDS patients. In acute cases, strongly positive outcomes were reported by 7 (70%) of 10 IDS patients and by 8 (57.2%) of 14 non-IDS patients (no statistically significant difference between sub-groups). The FU conditions most frequently treated with homeopathy were chronic periodontitis (19 patients) and acute periodontal abscess (11 patients). Analysis of PPD data was not feasible due to the small numbers of patients involved. Conclusion: Limited insight has been gained into the periodontal complaints treated by homeopathy in the UK. Due to small sample size and equivocal results, the interpretation of the patient-reported outcomes data is unclear. Positive findings obtained in the acute treatment setting suggest that this may be a promising area for research in periodontal homeopathy. Homeopathy (2013) 102, 242e247.

Keywords: Periodontal disease; Individualised homeopathic prescription; Patientreported outcomes; Periodontal pocket depth

*Correspondence: S Farrer, Faculty of Homeopathy, 29 Park Street West, Luton LU1 3BE, UK. E-mail: sue@ Received 14 May 2012; revised 27 January 2013; accepted 26 June 2013

Introduction

In clinical research, investigators are interested in whether interventions in complementary/alternative medicine (CAM) are at least as effective and safe as standard therapies. Conventional therapeutic strategies for limiting periodontal disease include local and non-specific systemic short-term measures, both of which are well documented.1e7 However, clinical best practice guidelines

contraindicate the long-term use of systemic antibiotics and localised antimicrobials as adjuncts in periodontal therapy, and there is little evidence to support their longterm effectiveness8e10 or indeed that of routine scaling.11

The current peer-reviewed evidence for homeopathic research in human medicine comprises 156 randomised controlled trials (RCTs) in homeopathy: 41% have shown positive results, while only 7% have been negative; the others have been non-conclusive.12 Four out of five systematic reviews have also returned broadly positive results.12 Very little controlled dental homeopathic research has been conducted to date.

In periodontal research, the efficacy of any new treatment has to be interpreted against recognised best practice measures of care.13 Periodontal therapeutic adjunctive treatments are either systemically or topically applied depending on the requirements of each individual case. Similar administration routes are applied in homeopathic prescribing, except that core values are based on "like cures like" and minimum dose according to each case presentation.14

The homeopathic treatment of dental conditions is sometimes carried out in association with interventional dental surgery (IDS), including routine scaling, and/or the use of conventional medications. As previously noted,15 such interventions make it impossible to distinguish any treatment effects specific to the homeopathic medicine alone.

The present extension of our dental data collection pilot study16 therefore focuses exclusively on periodontal homeopathy, since IDS in this context is relatively less frequent and the use of prescription drugs can be carefully monitored.

The objective of the current study is to identify any promising patterns of disease, clinical responses and/or homeopathic medicines, which may in turn help to target future research in periodontal homeopathy.

Specifically, the aims of the study are:

1. To gain insight into the periodontal complaints that dentists in the UK treat using homeopathy.

2. For follow-up (FU) cases, and with particular focus on whether patients received IDS: (a) to record patientassessed change in severity of the treated complaint (acute or chronic); (b) to determine periodontal pocket depth (PPD) changes; (c) to note any change in patients' use of conventional medication for their periodontal complaint since the start of any homeopathic intervention.

Methods

Three dental surgeons in England (PD, LG, CN) contributed independently to the study. Each dentist is qualified homeopathically to the standard of Diplomate Member of the Faculty of Homeopathy (DFHom). The 3 dentists collected data from consecutive homeopathy appointments of periodontal patients during the 18-month period, 1st February 2008 to 31st July 2009. Individualised homeopathic prescriptions were given for those periodontal conditions during the study period: as per normal homeopathic

Homeopathic prescribing for chronic and acute periodontal conditions S Farrer et al

243

practice, prescriptions could be changed by the practitioner at appointments during the course of treatment. Conventional medical prescriptions were available as required and, if used, they were recorded. Because of the known association between smoking and periodontal disease,17 smokers within the cohort of patients were also identified.

A spreadsheet, based on our pilot study,16 enabled recording of all consecutive periodontal homeopathy appointments under the following column headings; cases of homeopathic prophylaxis or `immunisation' were not recorded:

(1) Appointment date (day, month); (2) unique patient identity number; (3) age; (4) gender; (5) whether patient is a current smoker; (6) the main problem being treated (non-listed diagnoses or descriptions could be inserted by dentists as required); (7) whether problem is `acute' or `chronic'; (8) whether, in relation to the previous 12 months, this is a new or a FU appointment for the same problem; (9) patient-assessed change in the treated problem at FU compared with the first homeopathic consultation, using 7-point outcome Likert scale (see below); (10) homeopathic medicine/s prescribed at this consultation; (11) whether any IDS today for this condition; (12) whether any conventional medication (i.e. prescription drugs, dietary advice, etc.) for this condition.

A periodontal problem was classified as chronic if it had been apparent for at least 3 months. An acute flare-up of a chronic condition was labelled in the spreadsheet as `chronic' since this phase is merely an exacerbation of an underlying chronic inflammatory condition.

Likert scale Patient-assessed clinical outcomes were ascertained and

recorded as previously described.16 Patients' responses were transcribed by the dentist as follows: major deterioration = ?3; moderate deterioration = ?2; mild deterioration = ?1; no change or unsure = 0; mild improvement = +1; moderate improvement = +2; major improvement = +3.

PPD and community periodontal index of treatment need (CPITN)

A standard 15 mm R198 probe (Swallow Dental Supplies Ltd., Silsden, West Yorkshire, UK) was used to measure PPD in each sextant of the mouth. The score was recorded to reflect the clinically worst measurement in each case. A CPITN sextant averaged score was applied to eliminate the differential between bacterially active and non-active periodontal pockets.18 For the purposes of data presentation, the upper right molar sextant was selected as being representative of possible bacterially active periodontal pocketing due to patients' potential lack of dexterity when attempting oral hygiene measures.

Research ethics The Chair of the South Bedfordshire Research Ethics

Committee (REC) advised that a study of this type did not require REC approval.

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Homeopathic prescribing for chronic and acute periodontal conditions S Farrer et al

244 Methods of spreadsheet analysis

Upon receipt of final spreadsheets at the end of the project, the original data were filtered for missing or likely erroneous data and rectified where possible in consultation with the dentist concerned. Terminology for non-listed periodontal conditions was reconciled to eliminate duplications or ambiguity.

Appointments data from all 3 dentists were consolidated into a master spreadsheet. Analysis of outcomes focused on "last" appointments only e i.e. on the number of individual periodontal conditions treated, irrespective of whether they were previously treated by the dentist once, twice or more often. The outcome score recorded at this last FU appointment per case during the 18 months was thus the single value analysed and presented for that patient within the descriptive statistics presented below. Likewise, the homeopathic medicine prescribed at this last recorded appointment was the single one used per case in the data analysis.

Chi-square (c2) statistical testing was used, when appropriate, to investigate any significant differences between the frequencies of scores recorded over all conditions (acute or chronic) for those cases receiving and those not receiving IDS, the null hypothesis of no significant difference between 2 groups being rejected at the level of P # 0.05 (c2 = 3.84, 1 df). In cases where the expected frequency was 0.05). A score of ?2 or ?3 (moderate or major deterioration) was recorded in 0%. Of the remaining scores, 0% were ?1, 16.7% were 0, and 50.0% were +1 (Table 2b). Overall, 83.3% of patients reported a positive outcome. There were no missing outcomes data at last appointment. None of these patients was receiving conventional medication. Two of this group (33.3%) were smokers.

The largest set of data was available for chronic periodontitis (n = 15 non-IDS; n = 4 IDS). For the 15 nonIDS cases, a score of +2 or +3 comprised 6.7% of the patient-reported outcomes; for the 4 IDS cases, a score of +2 or +3 comprised 50.0% of the patient-reported outcomes (Tables 2a and 2b). There was no significant difference between the 2 percentages (Fisher's Exact test: P = 0.09).

Homeopathic prescribing for chronic and acute periodontal conditions S Farrer et al

245 Table 2a Summary of outcomes at final FU appointment for chronic cases without IDS

Condition

No. last FUs ?3 Score ?2 Score ?1 Score 0 Score +1 Score +2 Score +3 Score Conv. Smoker med.

Chronic periodontitis 15

Periodontal pain

1

All conditions

16

0.0% 0.0% 0.0%

0.0% 0.0% 0.0%

6.7% 0.0% 6.3%

13.3% 0.0%

12.5%

73.3% 100.0%

75.0%

6.7% 0.0% 6.3%

0.0% 0.0% 0.0%

0.0% 0.0% 0.0%

13.3% 0.0%

12.5%

Conv. med. = conventional medication.

Table 2b Summary of outcomes at final FU appointment for chronic cases with IDS

Condition

No. last FUs ?3 Score ?2 Score ?1 Score 0 Score +1 Score +2 Score +3 Score Conv. Smoker med.

Chronic periodontitis 4

Periodontal pain

1

Rapidly progressive 1

Periodontitis

All conditions

6

0.0% 0.0% 0.0%

0.0%

0.0% 0.0% 0.0%

0.0%

0.0% 0.0% 0.0%

0.0%

25.0% 0.0% 0.0%

16.7%

25.0% 100.0% 100.0%

50.0%

50.0% 0.0% 0.0%

33.3%

0.0% 0.0% 0.0%

0.0%

0.0% 0.0% 0.0%

0.0%

25.0% 0.0%

100.0%

33.3%

Conv. med. = conventional medication.

PPD: For the chronic periodontitis patients as a group, the mean PPD of the upper right molar sextant did not change perceptibly over the first 8 homeopathic appointments (4.57 ? (SD) 1.60 mm to 4.64 ? (SD) 1.74 mm per appointment; n = 14 patients).

Acute conditions The last recorded FU appointment number for these 24

cases varied between 2 and 10 (median, 2). Of the 24 acute cases, the results were sub-divided into those cases who did not receive IDS (n = 14) and those who did so (n = 10).

For the 14 non-IDS cases, a score of +2 or +3 (moderate or major improvement) was reported overall in 57.2% (8 cases); a score of ?2 or ?3 (moderate or major deterioration) was recorded in 0%; of the remaining scores, 35.7% were +1 (Table 3a). Overall, 92.9% of patients reported a positive outcome. There were missing outcomes at last appointments in 7.1% of cases (i.e. one patient); the Chisquare calculation was carried out on the remaining n = 13 patients. Six (42.9%) of this group of patients were smokers. Single patients (n = 1) per condition reported an outcome of either +1 or +2, the latter being a case of pregnancy gingivitis.

For the 10 IDS cases, a score of +2 or +3 (moderate or major improvement) was reported overall in 70.0% (7 cases); this is not significantly different from the 57.2% recorded in non-IDS patients (c2 = 0.18; P > 0.05). A score of ?2 or ?3 (moderate or major deterioration) was recorded in 0%; of the remaining scores, 10.0% were 0 and 20.0% were +1 (Table 3b). Overall, 90.0% of patients reported a positive outcome. Three (30%) of these 10 patients were smokers.

The largest set of data was available for acute periodontal abscess (n = 6 non-IDS; n = 5 IDS). For the 6 non-IDS cases, a score of +2/+3 comprised 50% of the patient-reported outcomes (Table 3a). For the 5 IDS cases, a score of +2/+3 comprised 60.0% of the patient-reported outcomes (Table 3b). There was no significant difference

between the 2 percentages (c2 = 0.11; P > 0.05). Single patients per condition (n = 1 cases of acute ulceromembranous gingivitis [AUG] and epulis) each reported an outcome of +2.

PPD: There were insufficient numbers of FU appointments for acute periodontal abscess or any other particular condition to enable PPD to be analysed meaningfully.

Discussion

In this project standard protocols have been observed, with the understanding that homeopathic intervention may influence disease progression but that a much larger and controlled study would be needed to establish the clinical significance of any treatment effect.19 The study identified a number of chronic and acute periodontal complaints that 3 dentists in the UK treat using homeopathy, as well as the patient-reported changes associated with treatment in each case.

The small number of participating practitioners has prevented us from coming to clear conclusions in relation to our first aim (to gain insight into the periodontal complaints that dentists in the UK treat using homeopathy): with merely n = 3 practitioners in England, we cannot make useful generalisations about UK dental practice. In connection with our second aim, only 2 conditions (chronic periodontitis and acute periodontal abscess) have sufficient numbers of cases to justify even tentative comments. Small numbers also preclude meaningful commentary on changes in PPD, in patients' use of conventional medication, or the influence of smoking.

A further limitation of our project is that, by definition, an observational study involves no controls and is therefore unable to take into account other factors such as regression to the mean or the general improvement or decline of symptoms over time. From our data, therefore, it is not possible to infer any causal relationship between reported outcome and the treatment, whether homeopathy or conventional surgery. Nevertheless, the project benefited

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Homeopathic prescribing for chronic and acute periodontal conditions S Farrer et al

246 Table 3a Summary of outcomes at final FU appointment for acute cases without IDS

Condition

No. last FUs ?3 Score ?2 Score ?1 Score 0 Score +1 Score +2 Score +3 Score Conv. Smoker % med. %

Acute periodontal abscess 6

Periodontal trauma

1

AUG

1

Pericoronitis*

3

Oral mucosal infection

2

Pregnancy gingivitis

1

All conditions

14

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

0.0%

50.0%

0.0% 50.0% 0.0

0.0% 100.0%

0.0% 0.0% 0.0

0.0% 100.0%

0.0% 0.0% 0.0

0.0%

0.0% 66.7% 0.0% 0.0

0.0%

0.0% 50.0% 50.0% 0.0

0.0%

0.0% 100.0% 0.0% 0.0

0.0% 35.7% 28.6% 28.6% 0.0

33.3 100.0 100.0

33.3 50.0 100.0 42.9

2 Records were first and only appointments, which are not included in the table. Conv. med. = conventional medication. * = 1 missing score.

Table 3b Summary of outcomes at final FU appointment for acute cases with IDS

Condition

No. last FUs ?3 Score ?2 Score ?1 Score 0 Score +1 Score +2 Score +3 Score Conv. Smoker % med. %

Acute periodontal 5

abscess

AUG

1

Pericoronitis

3

Epulis

1

All conditions 10

0.0%

0.0% 0.0% 0.0% 0.0%

0.0%

0.0% 0.0% 0.0% 0.0%

0.0%

0.0% 0.0% 0.0% 0.0%

20.0% 20.0%

40.0% 20.0%

0.0

0.0% 0.0% 100.0% 0.0%

0.0

0.0% 33.3%

66.7% 0.0% 33.3

0.0% 0.0% 100.0% 0.0%

0.0

10.0% 20.0%

60.0% 10.0% 10.0

0.0

100.0 33.3

100.0 30.0

3 Records were first and only appointments, which are not included in the table. Conv. med. = conventional medication.

from the 18-month period of its data collection, addressing one limitation of the 6-month pilot work: a full course of homeopathy appointments per chronic case was more likely to have been achieved in this longer time frame.

In the acute cases reported here, the rate of high positive outcomes (up to 70% with outcome scores of +2 or +3) is similar to the findings reported in our earlier pilot study;16 there is no evidence of any impact of IDS on the percentage data. This observation is evident in periodontal abscess and in pericoronitis, though small patient numbers limit the conclusions. It is notable that for some acute conditions, in which we have data for only a single individual, there was a reported outcome of +2; this is most interestingly the case for gingivitis associated with pregnancy, during which women might wisely not take allopathic drugs such as antibiotics.20 In chronic cases, however, the rate of high positive outcomes was considerably less than in our previous report; statistical analysis did not confirm whether or not such patients have better outcomes when conventional surgery is included in the treatment strategy. It should also be borne in mind that not all patients will have a similar interpretation of what constitutes moderate or major improvement, for example, and so the Likert score should not be regarded as a precise measure of outcome.

Periodontosis is a degenerative pathology of multifactorial aetiology overlaid by individual genetic patterning.21 Long-term cellular toxicity, deoxygenation and intracellular enzyme damage lead to both hard and soft tissue destruction.22 This diseased state is compensated for by the individual's immune response, where the organism repeatedly strives to achieve homeostasis. Thus, in the acute stages of the inflammatory cycle, where connective

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tissue matrix changes have taken place but there is little cellular destruction, excretory processes enable toxin removal, and this is where a homeopathic medicine may theoretically assist and be effective in regulating the inflammatory process.23 As the data indicate (Table 3a), moderate/major improvements i.e. +2/+3 scores were achieved in a total of 57.2% of acute periodontal cases without IDS or conventional therapeutic strategies.

In progressive chronic degenerative phases of periodontosis, on the other hand, where tissue toxin deposition and impregnation incur intracellular enzyme damage, the therapeutic intervention of a single homeopathic medicine is seen to be less supportive of the inflammatory response. As indicated by Table 2a, scores of +1 were reported in 75% of those chronic periodontal cases, whereas scores of +2/+3 were achieved in only 6.3% of cases where IDS or conventional therapeutics were not employed. This expected result opens up the debate for trialling homeopathic complex medicines that target different aspects of the cytokine system, which in turn might lead to further research in the future.

Conclusions

Because of the small sample size and equivocal findings, the interpretation of the patient-reported outcomes data remains unclear. Strongly positive outcomes were seldom reported in chronic cases but were more prominent in acute cases, particularly in periodontal abscess. Promising areas for future periodontal research in homeopathy may best lie in the acute treatment setting and perhaps in the immunological targeting of chronic case management.

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